RespiratoryClinical evaluation/Patient assessmentsBlood tests- too look for AChR antibodies Muscle and nerve testsScan of the thymus glandThyroid function testsElectrophysiological investigations- can give false pos and neg resultsIce Pack testEdrophonium test (a rapid anticholinesterase inhibitor)Breathing tests are performed on those with chest weaknessDrugsThymectomy – removal of the thymusPlasma exchange - indicated for management of myasthenic crisisAn immune organ located between the heart and sternum.The thymus gland is thought to be a main source of the abnormal antibodies.Usually caused by tumorsAll MG diagnosis should undergo scan of the thymus to rule out this as the causeFirst line treatmentInhibiting acetylcholinesterase can boost the concentration of ACh in synapse facilitate muscle activation and contractionPyridostigmine – typical maintenance dose - 60mg four to six times a daySide effects – nausea, diarrhea, abdominal cramps, increased saliva/mucus Propantheline 15mg (taken 15-30mins before pyridostigmine dose)

Started two months prior to going to the ERFive weeks before he went into ER with simular symptoms

Diagnose with Bell's Palsy and sent home with prescriptions for predisone and doxycyclinePast Medical HistoryHypertensionGastroesophogeal reflux disease (GERD)Mild arthritis of kneesAnxietyAllergic to penicillinExamination Day 1Current medications: Hydrochlorothiazide-lisinopril (BP med) 25mg/20mgOmeprazole (heartburn med) 20 mgPulse: 106Respirations: 24BP: 160/88BMI: 38Oxygen saturation on room air ranged from 92%to 98%Blood tests included complete blood count, complete metabolic panel, and thyroid stimulating hormone. All were within normal limits.MRI- results unsatisfactory due to paitent movement; no gross abnormality was notedSymptomsA neurologist scheduled a MRI of the brain and cervical spine as an outpatient the next day. Never took place because the paitent returned by ambulance the next morning His vital signs were within normal range and he attributed his symptoms to anxiety. Final DiagnosisWithin three days the patient was diagnosed with Myasthenia Gravis after a positive acetylcholine receptor antibody test. A CAT scan of the chest revealed a mediastinal mass.Thymectomy (removing thymus) was performed the next day.Pathology results revealed a benign tumor Postsurgery- transferred to a nursing facility for medication management, and physical/occupational therapyPhysical Examination Day 2Changed when compared to previous dayExhibited left-side ptosis, vertical and lateral nystagmus (fast, uncontrollable movements) of the left eye, decresed motor stregths of the deltoids and neck flexors, and plantar reflex was downgoingBlood work: creatinine kinase (CK) normal; antinuclear antibody panel; positiveFinal Diagnosis Continued...Medications included:Pryidostigmine bromide- (anticholinesterase inhibitor) 60mg given by mouth every six hours for symptom controlImmunosuppressive therapyPrednisone- 80mg once a dayMyasthenic CrisisOccurs when MG symptoms are severeCausing respiratory failureIntublation and ventilation20% will develop myasthenic crisisOcularBulbarPatientCase StudyA case

report featuring a diagnostic challenge in the emergency departmentConclusionMyasthenia gravis is a pure motor syndrome disease characterized by fluctuating muscle weakness and fatigue and is made worse by sustained muscle use. In this case, a 41-year-old male was first diagnosed with Bell's Palsy.Increased complications of his symptoms led to the diagnosis of myasthenia gravis. Doctors, NP, and PAs, must include MG in the differential diagnosis with any report of a specific muscle weakness that can be reproduced and exacerbated with sustained muscle use. These considerations will lead to earlier diagnosis and treatment. Purpose: To describe an instructive case of neurological disease encountered by a NP student in the emergency department.

Data Sources: Findings from the history, physical examination, and diagnostic testing of a 41-year old caucasian male with neck weakness and pain.

Conclusions: MG is a pure motor syndrome disease characterized by fluctuating muscle weakness and fatigue and is exacerbated by sustained muscle use. Usually caused by autoimmune process, chronic & progressive Multiple PT encounters w/healthcare system occurr regularly prior to diagnosis. Many tx options now exist that enhance quality of life and improve function.

Implications for practice: The NP needs to include MG in differential diagnosis w/any report of muscle weakness or neurological, respiratory or ophthalmic complaint. These considerations will lead to earlier diagnosis and tx. Abstract